RAND: Net Gain of 9.3 Million American Adults with Health Insurance

flying cadeuciiUsing a survey fielded by the RAND American Life Panel, we estimate a net gain of 9.3 million in the number of American adults with health insurance coverage from September 2013 to mid-March 2014.

The survey, drawn from a small but nationally representative sample, indicates that this significant uptick in insurance coverage has come not only from enrollment in the new marketplaces established under the Affordable Care Act (ACA), but also from new enrollment in employer coverage and Medicaid.

Put another way, the survey estimates that the share of uninsured American adults has dropped over the measured period from 20.5 percent to 15.8 percent. Among those gaining coverage, most enrolled through employer-sponsored coverage or Medicaid.

Although a total of 3.9 million people enrolled in marketplace plans, only 1.4 million of these individuals were previously uninsured. Our marketplace enrollment numbers are lower than those reported by the federal government at least in part because our data do not fully capture the surge in enrollment that occurred in late March 2014.

Using the RAND American Life Panel, a nationally representative panel of individuals who regularly participate in surveys, we have conducted monthly surveys since November 2013 about insurance choices and public opinion. This particular survey work—which is ongoing—is known as the RAND Health Reform Opinion Study(RHROS).

We match these data with data collected in September 2013 about insurance choices. The results presented here are based on 2,425 adults between the ages of 18 and 64 who responded in both March 2014 and September 2013.

People shift from one type of health insurance to another for a number of reasons, such as job changes or marital status changes. Our survey work can’t say for certain which of these shifts are due to the ACA and which are due to other factors, but we can draw some limited conclusions.

A more detailed report describing the results summarized below can be found here.

  • Of the 40.7 million who were uninsured in 2013, 14.5 million gained coverage, but 5.2 million of the insured lost coverage, for a net gain in coverage of approximately 9.3 million. This represents a drop in the share of the population that is uninsured from 20.5 percent to 15.8 percent.
  • The 9.3 million person increase in insurance is driven not only by enrollment in marketplace plans, but also by gains in employer-sponsored insurance (ESI) and Medicaid.
  • Enrollment in ESI increased by 8.2 million.
  • Medicaid enrollment increased by 5.9 million. New enrollees are primarily drawn from those who were uninsured in 2013, or those who had “other” forms of insurance, including Medicare, retiree health insurance, and other government plans.
  • According to our estimates, 3.9 million were covered through the state and federal marketplaces as of mid-March 2014. This figure does not fully capture the enrollment surge that occurred in late March.
  • For most people the ACA has not changed their health insurance coverage. Among adults, 80 percent still had the same form of coverage in March 2014 as in September 2013. Notably, more than 100 million had ESI before and have ESI now, while 26 million remain uninsured.
  • Of those who were previously uninsured but are now insured, 7.2 million gained ESI, 3.6 million are now covered by Medicaid, 1.4 million have signed up through a marketplace, while the remainder gained coverage through other sources.
  • Our estimates suggest that only about one-third of new marketplace enrollees were previously uninsured. While this percentage seems low in absolute terms, it is slightly higher than an earlier figure reported by McKinsey & Company.[1]
  • Among the 7.8 million people who were enrolled in off-marketplace individual market plans in early 2014, 7.3 million were previously insured; 5.4 million were previously insured through an individual market plan.
  • Less than one million who previously had individual market insurance transitioned to being uninsured. While we cannot tell if these people lost their insurance due to cancellation or because they simply felt the cost was too high, the overall number represents less than one percent of people between the ages of 18 and 64.

The survey results reported here were collected through March 28, 2014, but many panelists responded earlier in the month and may have made new insurance choices since then. Respondents will be surveyed again in April and our figures will be updated when new data is available.

Given the strong interest in understanding the impact of the ACA, a variety of different organizations, including the Urban Institute, are conducting surveys to estimate the impact of the ACA on insurance enrollment. When making comparisons, it is important to keep in mind that there is always a margin of error.

In this case, because we are extrapolating from a small survey to the entire U.S. population, the margin of error is relatively large. For example, while we estimate 9.3 million individuals become newly insured, the margin of error is 3.5 million people. [2] Furthermore, the timing of surveys may vary. Given the surge in enrollment at the end of March, whether that period is included in the survey may dramatically affect results.

Thus, it should not be surprising that our estimates may not match perfectly.

Over the coming months and years, further change can be expected as people become more familiar with the law, the individual mandate penalties increase to their highest levels, the employer mandate kicks in, and other changes occur. But early evidence from our survey indicates that the ACA has already led to a substantial increase in insurance coverage.

Consistent with the design of the ACA, this gain in insurance has come not only from new enrollment in the marketplaces, but also from new enrollment in employer coverage and Medicaid.

Katherine Grace Carman (@KGCarman) is an economist and Christine Eibner (@Chrissyeibner) is a senior economist at the nonprofit, nonpartisan RAND Corporation. This post originally appeared in The RAND Blog

14 replies »

  1. The dominant problem with the ACA is that it has no clever or ingenious ways to reduce prices. Every trite and banal shibboleth known to man was tossed into the bill. We deserved more excellence. Every health economist says that the cost of new technology is a major cost driver. Accordingly, should not US patent laws be discussed? More pre-marketing trials? A patent is supposed to be useful. Can’t we cause innovators to show this before release more consistently? We know that HSAs and CAT policies work for many folks, yet these are hardly discussed. We know that monopsonic purchasing works. Why is this not utilized? Why can’t docs compete with each other on procedure prices? Are we slaves to price schedules?

    To find things that are gems within the bill is like searching through the garbage. Not enough thinking went into it. I think it could be fixed by simply allowing insurers to sell anything they want in the exchanges–including underwritten plans–and subsidizing the poor by means testing and medical needs testing. Or we could give everyone, rich and poor, a voucher per year–enough for a cat policy., and allow HSAs to bloom.

    It’ll probably be hammered into something that will work when the folks with rigid ideologies finally die off. So it’s possible our grand kids will like us.

  2. There is no reason that an expansion of Medicaid needs to be part of the ACA. It could have been part of a completely separate initiative.

    In fact, because of the political controversy surrounding the ACA, a number of (Red) states decided NOT to expand Medicaid. They may have made a different decision if the ACA hadn’t been such a “hot potato”.

  3. We needed the ACA because Medicaid expansion is part of the ACA. And employer mandates on coverage are part of the expansion. Also young adults who are on their parents’ employer plans are included in the Employer numbers so that’s another feature of the ACA.

  4. The same thing happened in Massachusetts. Their individual mandate and public exchange reform initiative had the curious effect of actually triggering a jump in those covered by employer sponsored insurance. Many experts had written off this as an anomaly of the Massachusetts economy and labor market, but perhaps there’s an element of behavioral economics taking place here as well. Employers electing to offer coverage rather than take the penalty, and employees signing up rather than waiving coverage.

  5. The “gold standard” or rather the “brass that leaves a green stain on your fingers” standard is the Census Bureau analysis of Poverty and Insurance coverage. That’s the only one that is reasonably consistent and goes back a number of years, and we won’t have that for a month or two. And that one probably won’t have moved at all.

  6. Perhaps a dumb question but:

    If the majority of the new coverage is from Medicaid and Employers, why did we need the ACA?

  7. I take the middle position, and I am not a fan of the ACA. I really think it’s too early to make any prediction about the success of the law.
    It is called the Patient Protection and Affordable Care Act. By patient protection, I assume it means protection from patients being drowned by medical bills, therefore, part of that is insuring them against financial ruin(as well as getting the health care they need). However, this law has gone further by mandating what other types of benefits should be included in those insurance plans. If you accept that as of right now about 9 million more are insured out of the estimated 45-50 million previously, thats about 20% of the uninsured, now covered. Not bad, really for the first year.

    What remains to be seen is how many of these stay covered, assuming the rates stay affordable. If they don’t, or we have another recession, that will force either more on to subsidies or more on Medicaid. And will Medicaid patients be able to get the care they need from primary care offices?
    My other question is what happens to the affordability of health care in general? If many people have high copays, and cannot afford the care they need, then you have reneged on the protection part as well as the affordability part.
    And, ultimately will Americans be happy with the product they have purchased?

  8. An estimated 9.3M newly insured with a margin of error of 37%. So, let’s cast that another way. If a drug company approached a health plan seeking coverage and reimbursement for a new product, but said that their data had a 37% margin of error, they’d get laughed out of the room. Well, they would unless they were pitching Aetna, which would probably send a letter to members about the great new product. Alas, I digress…

    I think Bubba is absolutely right: if we can’t understand the relationship(s) here, how can we make credible estimates?

    The data that matters, in my view, is the political standing of the ACA. According to the Kaiser Family Foundation tracking poll, which goes back to when the law was signed, public perception of the law since April 2010 is almost uniformly negative. The negativity holds true at all income levels, older and younger adults, both genders, and, most importantly, among political independents (such as yours truly).

    When you combine the folly of the ACA’s lunatic support for workplace wellness, with the President’s mendacity (you can keep your plan, you can keep your doctor, etc.), the ACA’s troubles won’t end anytime soon, enrollment data notwithstanding. Health policy in our country is just about politics and money. To paraphrase two famous Democrats, we did build that, and all this law does is make people and organizations who were fat, happy, and lazy even fatter, lazier, and happier. It’s what you get when you spend 50 years building a healthcare system that is about commerce, not health.

  9. @ Bubba Yes, a margin of error of 3.5 million is pretty big when you’re talking about 5 million people. This is not exactly the gold standard. .

    The key takeaway here is the % of newly insured, which is pretty close to McKinsey’s – which definitely means something ..

  10. I’m not sure we can go with a survey for something this complex

    if we can’t pretend to understand the relationship how do we make a serious estimate ..?